First, what is the July Effect? It represents an entire transition in the hospital, during which medical students become interns, interns become senior residents, and second or third-year residents become chief residents. All of the fellows are just starting out in their specialty of choice, and there are new attendings, fresh out of residency, who have entered their chosen field. Leadership in the hospital changes all at once, and this makes for a dynamic and uncertain environment as everyone tries to adjust to their new roles.

Secondly, what are the specific effects of this phenomenon? This question is open to interpretation – the recent study suggests that one of the effects is an increase in fatal medication errors. However, mistakes in the hospital (or in any system) only occur when a series of “errors” or “oversights” are made in unison. All of the safety nets which prevent fatal medication errors must have failed. What are these safety nets?

1. Residents, fellows, and attendings should adequately supervise the new interns who are ordering medications.

2. Medication doses on the electronic ordering system should have certain restrictions.

3. Nurses are often the only staff in the hospital who have access to the medications, and we rely on them to administer them properly.

4. Interns should be educated about when to ask questions, and they should be provided with very clear guidelines for basic medication dosages. They should know where to locate appropriate dosages, whether through an online reference or the hospital pharmacy directly.

5. Pharmacy can play a role in overseeing medication orders in the computer.

This is a list of fail-safes which, if effective, minimize the risk of fatal medication errors. There are similar back-up plans in place for other fatal medical errors, including everything from cardiopulmonary resuscitation to surgical procedures. It is only when every back-up fails that an error occurs.

Thus, if the July effect is real (and it seems hard to dismiss, based on evidence and common sense), the question is not, “Whose fault is it?” Instead, the question is, “How can we strengthen the safety nets that we have or create additional ones in order to minimize these errors?”

The first and most important step is to acknowledge that these errors are happening. Just as physicians have a difficult time coming to grips with their own mortality or invincibility, they also have a difficulty time confronting their mistakes. Guilt, fear of retribution from colleagues or patients, humiliation, or even arrogance can drive physicians to sweep their errors under the rug. And these emotions only build on themselves, so that the entire community is caught in a negative cycle of denial and shame rather than constructive analysis.

The second step is to create more fail-safes if necessary. But this can only be done if we admit to our mistakes and work together, with physicians, nurses, and residents, and commit to making our hospitals safer for patients.

I think two contributing factors to the July problem are: (1) hospital staff vacations tend to swell around that time. So you have staff, but they are not on their regular shift, or regular unit, or working with the regular co-workers. This perturbation alone apparently is not sufficient to create a spike in errors (the abstract says there was no such spike in the other months, like say December), but it could be seen to be a weakening of the safety net just when it’s needed most. The other is (2) It’s not just brand new residents coming in July. It’s newly rotated residents – that is, someone who knows the hospital but not that service or not that unit. I mention this because I recall that there was always a bit of chaos when the residents rotated (depending on the service) each month or so throughout the year. But that chaos was much worse in July because in July we had not just the usual monthly changing of the guard but also the introduction of brand new “I’ve never seen the inside of this hospital” personnel.

I’m not sure that much can be done about (2) but (1) could be handled with better coordination on the part of the people who create the nursing staff schedules. Some rules of thumb like “July is not the month to put your never before been charge nurse nurse on as charge nurse” and training the nursing staff in advance so that there are more who can reliably perform shift leadership duties even during “off” staff shifts might help.